Black and white and gray all over

The necessity for addressing gun violence is a black and white issue from the public health perspective, but how to incorporate mental health in gun control reform is a gray area.

On January 4, 2016, the White House announced President Obama’s executive actions for reducing gun violence in the USA. As expected, the announcement was met with an array of responses, from exultation to excoriation. The Administration’s roadmap to curbing gun-related assaults and deaths and improving safety comprises four plainly worded actions: keep guns out of the wrong hands through background checks; make our communities safer from gun violence; increase mental health treatment and reporting to the background check system; and shape the future of gun safety and technology. But the linguistic simplicity of the actions belies a much more complicated struggle between employing some common sense measures to keep guns “out of the wrong hands” and the role that mental health should have in that discussion.

Gun rights advocates have been quick to claim that mental illness is the catalyst for increasing rates of gun violence and mass shootings. While there is no doubt that the perpetrators of several high-profile shootings have been individuals with emotional disturbances, to suggest that mental illness is the primary precipitant in gun violence is patently incorrect. The relationship between mental illness and violence, and gun violence in particular, is one that is far more nuanced. And in order to respond to the epidemic of violence, gun policy reform must take a thoughtful and deliberate approach to the way in which mental illness is addressed and incorporated.

The most substantive piece of the executive action is the expansion of background checks. In addition to making clear that, regardless of the location of the point of sale, be it the internet, a gun show, or a store, anyone purchasing a firearm must go through a background check. When a background check is conducted, records in the National Instant Criminal Background Check System (NICS) are searched and indicate whether an individual is prohibited from possessing a firearm because of a felony, being addicted to a controlled substance, the subject of a restraining order, or having been adjudicated to the anachronistic category of “mentally defective”.

Previously, the information fed into NICS came from criminal courts. States were not required to provide mental health information, nor was the FBI permitted to investigate specific individual’s mental health capacity—a major loophole that allowed individuals who posed a serious mental health threat, but who did not have a criminal history, from legally purchasing firearms. But a Department of Health and Human Services (HHS) modification to the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule expands reporting entities to include organizations that make mental health determinations. More specifically, healthcare agencies that were unable to report in to NICS will now be able to report health records that could have an impact on an individual’s ability to purchase guns. Mental health adjudications could have wider reach than feeding into NICS and there has been little indication that adequate oversight will protect the health records of Americans who have had contact with mental health professionals and those who are not necessarily in the group of individuals with the highest risk of violence. Thus, physicians and mental health professionals in the USA should have an essential and well-defined role in making such adjudications, a function which stands in stark contrast to the current position of pro-gun lobbyists and politicians who would restrict that role.

Two weeks after the executive actions were announced, we are still in the earliest stages of the HIPAA modification and NICS reporting developments, which gives us a rare opportunity for the medical and health community to become more vocal agents of change. Instead of a chorus reiterating that guns are indeed a public health issue, it is a prime moment to recognize that those who work to protect health should have a say in when, how, and with whom we intervene. It’s time to make the “gray” part of gun control reform matter.